Relationship Between Smoking And Type 2 Diabetes Among UK Based Adolescents

Background information and rationale of the study

Smoking is one of the known risk factors of type two diabetes and has been found to be the known risk factor for insulin resistance, which is considered to be the precursor of diabetes. Smoking or exposure to second hand smoke causes inflammation in the body and can also cause oxidative stress, thus interfering with the proper functioning of the cell. Oxidative stresses can cause damage to the cells of the body can destroy the pancreatic cells leading to faulty diabetic control (Kim et al. 2016). Smoking increases the rate of inflammation. It also increases the level of oxidative stress in the body. The smoking damages the beta cell function and impairs endothelial functions. The exact mechanism by which smoking increases the risk of diabetes and decreases the rate of homeostasis of glucose is not known, but as per current evidences it has been found that smoking increases insulin resistance.  Responses of the C- peptide and insulin to oral glucose load has been found to be significantly higher among the smokers than the non- smokers. Apart from the insulin resistance it has been found that smoking is also related to dyslipidaemia, which is prone to atherosclerosis. Smokers having fasting triglycerides have been found to be linked T2D (Chang 2012). Considering the homeostasis of glucose, smoking generally has a negative effect on the control of glucose. In a population based study it has been proved that smoking has been associated positively in a dose dependant manner having an elevated level of (Chang 2012)..The combination of early years smoking and diabetes has increased dramatically all around the world and especially in the United Kingdom.

This research proposal aims to detect the relationship between the occurrence of T2D and smoking among the UK based adolescents. The proposal will also provide some statistical evidences over the prevalence of T2D in UK due to smoking among adolescents. It will also provide information about the predisposing factors behind smoking among adolescents, public awareness among adolescents and any governmental policies or anti-smoking campaigns that has been taken up so far for the cessations of smoking and the effectiveness of such awareness campaigns.

Tobacco smoking spread around the whole world after it originated in America. Early anecdotal evidences highlighted that, it is due to the addictive property of the tobacco that inspired research. However, the present molecular structure and the related health consequences influenced research on smoking (Dani and Balfour 2011). The history of smoking can be dated back to 5000 B.C, and with the arrival of the Europeans, tobacco-smoking spread rapidly. Smoking was not popular until early 1800. Right after the discovery of the relation of Tobacco with cancer, its association with the development of diabetes was found soon (Dani and Balfour 2011).

According to Chang (2012), smoking has been found to be an important cause of type 2 diabetes. Tobacco smokers have the greater risk of developing T2D than that of the non- smokers. According to the studies, people having T2D are exposed to higher levels of nicotine, insulin is less effective. People with diabetes who smokes cigarettes; require higher doses of insulin for controlling their blood sugar level. Chang (2012) have confirmed that the harmful effects of smoking on T2D are not only confined to diabetic microvascular complications. T2DM arising out of smoking leads to several other complications associated to diabetes. Kim et al. (2014) have reported of similar correlation between the consumption of tobacco and risk for diabetes. Another British study by Lajous et al. (2013) has shown that the risk of developing diabetes was about 1.7 after the adjustment of the confounding factors like age, body mass index, alcohol intake and rate of daily physical activity.

Contextual events related events and research related to smoking and diabetes

Akter et al. (2015) have conducted a study for examining the association between the smoking intensity and smoking cessation on the development of T2D. As per the result 1.16% of the non-smokers and the 1.34 % of the smokers have developed. The risk ratio was found to be higher among the individuals among the smokers.

According to Kim et al. (2017), T2D is creating a fiscal burden in the health care system of the entire nation. The paper had demonstrated that early-onset of smoking habits and smoking duration has been related to the development of T2D. This Korean study had discussed that at least 7.1 % of the South Korean men, 15.5 % of the women having smoking habits have developed diabetes compared to that of the control study.

In U.K about 3.6 millions of people have been diagnosed with diabetes, which is equivalent to 60% of the entire population. About 24,000 people die from diabetes in Wales and England every year. According to a systematic review consisting of 25 studies, 12 % of all the cases of diabetes found in U.K have been found to be attributed to smoking (Government of UK 2017). According to the Cancer prevention study, in a cohort of 275,190 men and 534,637 women, women who smoke have 74% higher chance of developing diabetes than men, with men’s rate of increase by 45 % (Ash. Action 2014). About 700 people in the United Kingdom are diagnosed with diabetes in every two minutes. Metabolic syndrome is an umbrella term for diabetes, high blood pressure and obesity. Association has been found between metabolic syndrome and diabetes.  A meta-analysis and systematic review by Holden et al. (2013) have proved that smoking increases the vulnerability of developing diabetic peripheral neuropathy.

Anjum et al. (2016) have identified the factors underlying smoking prevalence among adolescents. Some of the factors include cultural and social norms, the availability of smoking ingredients, lack of tobacco control policies and promoting of tobacco by the tobacco manufactures. Advertising and promotion has been found to be influencing the smoking behaviour of adolescents often to a greater extent. Anjum et al. (2016) have again stated that, having a smoker family member can increase the smoking risk among the teenagers. Some of the studies have also stated that smoking habits often start as an inspiration for the outlook or the ads performed by the role models. Hence, this study will also consider the factors responsible for smoking among adolescents.

In order to prevent smoking among adolescents, the United Kingdom government had taken several policies and strategies like “Smoking Kills”: A White Paper on Tobacco, strategies for reducing tobacco consumption and reduction of the drivers to smoke (Ash. Action. 2014).

Several tobacco control advertisements and awareness campaigns have been made in the United Kingdom to control smoking among adolescents. Still the rate of smoking has not fallen to a considerable rate (Sims et al. 2016). Adolescents are often indifferent to all the awareness campaigns and smokes for maintaining the social decorum amidst friends. Peer influence has been identified as one of the most important predictors of smoking and kids having friends who smoke are more likely to smoke. In spite of antismoking policies and the laws, UK’s antismoking efforts have not reached its peaks and there are still 9.1 million smokers present in the United Kingdom. It has to be remembered that taxation, banning and health literacy, they all have their limits. Furthermore, lack of exact data regarding the prevalence of smoking and diabetes also contributed to the failure. It has to be remembered that smoking is a contribution of many chronic diseases and any action that has been taken till now has focused only on the smoking cessation as a whole. Smoking cessation should also be integrated with diabetes prevention strategies or cancer prevention strategies, or during diabetes awareness campaigns, people should also be educated about the correlation of smoking and diabetes.   Chang (2012) have argued that apart from smoking cigarettes, consumption of nicotine as an addictive drug poses harmful effects just as smoking. In spite of the tobacco control plan that has been undertaken it has been found that, it failed to reduce the prevalence of smoking amongst the young people from 8 % to 3 %. The policy also could not reduce smoking in the pregnancy period (Chang 2012).  

Statistical evidences

Although diabetes due to smoking is an important problem in the United Kingdom, however very few systematic reviews on UK context is present to evaluate the fact that smoking in the early years might lead to diabetes in adult years. Furthermore, the policies that have been adopted so far have not proven to be that much efficient in controlling smoking cessation related to diabetes. Hence the research gap that has been identified is that no such systematic reviews has been identified, hence we propose to conduct a secondary research to find out the association of smoking in the early years and diabetes in the United kingdom. 

The aim of the study is to explore the relationship between smoking and development of Type-2 Diabetes (T2DM) among the younger adults residing in the United Kingdom (UK)

1. To study the rate of incidence and the underlying causes of smoking among the younger adults residing in the UK
2. To study how the vulnerability of developing T2DM increases with smoking among the young adults in the later stages of their life under UK perspective
3. To analyse the level of awareness of T2DM management among the younger adults in the UK
4. To study the effective government initiatives for the smoking cessation in the UK
5. Further recommendation in order to bring effective change in the social care and management policy of smoking among young adults in the UK

Methodology is an important part of research. It allows the researcher to study the research problem (McCusker and Gunaydin2015). According to Saunders and Rojon (2014), research methodology is different from the research methods. Research methodology mainly encompasses logic backed by strong philosophy behind the specific research approach. On the other hand, methods are regarded as tools which are used in order to accumulate and to analyze the information used during the research process. In order to conduct this selected systematic review, the chosen path of methodology will be based on the research question and the type of research design as guided data stated by Gough Oliver and Thomas (2012). As stated earlier, this systematic review is to study the relationship between smoking and T2DM development. Therefore, the answer to this research questions will be regarded as the main objective rather than containing numerous subjective realities.

The mode of the study selected for this research is a qualitative systematic review. According to Ross (2012), qualitative research encompasses detailed study and proper understanding of the difficult phenomenon with the help of the thematic analysis. This is mainly initiated through observation and then collection of data. The overall approach helps in recognizing a specific pattern of data and thereby helping to generate new theories about any prevailing phenomenon (Ross 2012). Gargon et al. (2014) are of the opinion that a high-quality systematic review is described as the most reliable resource of evidence to develop new policy guidelines for improvement of any public health concern. The purpose of a systematic review is to provide a meticulous summary of all the primary research available online in relation to the selected research question. A systematic review makes use of the all the relevant literature in order to erect a cumulative set of information. Thus systematic review is often regarded as secondary research. Under the perspective to this research, it can be highlighted that a systematic review of literature will help to establish a state of existing knowledge about smoking and its relation to diabetes mellitus and thereby helping to generate the social policy guidelines for the improvement of the health-related status of the younger adults.

The main research philosophy that will be used while conducting this secondary qualitative research is interpretivism research philosophy. According to Bergh and Ketchen (2011), the research philosophy of intrepretivism is chosen over the positivism research philosophy while conducting qualitative research because it assists the researcher to group together the varied approaches that includes the phenomenology, social constructivism as well as hermeneutics. All these approaches reject the objectivist view. Thus selecting the interpretivism research philosophy will enable the researcher to accumulate diverse degree of information and then cumulate it into a new evolving theory. Since both the qualitative and quantitative data will be selected to conduct this review of literature, the positivistic research approach was ruled as. Positivistic research approach mostly deals with numerical data and statistics and thus is suitable for quantitative research (Bergh and Ketchen 2011). With the help of interpretivism research philosophy, it will be helpful to analyze the problem underlying smoking and what young adults think about smoking and their knowledge about T2DM development.

Literary evidences

The main research approach that will be used for this qualitative research is inductive research approach. Crowther and Lancaster (2012) stated that inductive research approach assists in generation of new theory from the prevailing source of information. On the other hand, the deductive research approach is based on any existing theory. The selection of the inductive research approach will enable the researcher to compare the prevalence of smoking among the young adults in the UK and how this prevalence ration promotes the development of T2DM.

The research will select the descriptive style research design in order to conduct the qualitative research. According to the data highlighted by Ellis and Levy (2012), descriptive type research design will enable the researcher to describe the relationship between the cause and effect. Here cause is smoking of tobacco and the effect is: development of T2DM. The descriptive type research design will be used in comparison to the explanatory research design as descriptive type research design help to perform comparative analysis. According to Lambert and Lambert (2012), descriptive type research design helps the author to perform descriptive analysis of the informational contents and organizing that data in logical flow in order to generate a new theory. Moreover, the descriptive type of research design will help the author will successfully conduct the thematic analysis of the data.

The systematic review will be based on the review of the articles which are published online in the electronic databases. This is regarded as the first step of the qualitative research for the conduction of the systematic review in an organised manner. Searching of the literary articles in the electronic databases will help the researcher to select authentic yet relevant studies those are published previously in renowned scientific journals available online, mainly peered reviewed journals. The search of the literary articles will be done by the use of the keywords.

The preliminary search of the peered reviewed articles will be done by the use of the electronic databases like Pubmed, MEDLINE, ScienceDirect and Cochrane. These electronic databases were selected for the research because these electronic databases are more closely associated with the aim of this research. Parahoo (2014) stated that before conducting a systematic review, it is mandatory to perform a thorough search of the literary articles that are already published online in the form of reviews or meta-analysis or in the form of narrative reviews. Parahoo (2014) stated that this helps to reduce the risk of getting duplicate work and thus enabling the researcher to conduct a research. By following this concept, the researcher performed a search of the literary articles in the Crochrane Database for systematic Reviews with the help to keywords which is mentioned in the “keyword table” below. The search for the articles within the last 5 years provided no significant hits. This helped the author to come to a conclusion that there are no previous reviews based on the relationship of T2DM and smoking among the young adults in the UK. This approach coincided with the information highlighted by Holloway and Wheeler (2010). Holloway and Wheeler (2010) stated that conduction of the preliminary search of the literary articles in the Cochrane database assists to successfully highlight the gap in the research and thus helping to conduct a novel research with a unique research approach.

Aveyard (2014) stated that the search of the literary articles online must be guided by a distinct and a clear plan. In relation to this, Coughlan Cronin and Ryan (2013) highlighted that in order to have clear and a distinct plan for the selection of the literary articles online is manly guided by the principle of the inclusion and exclusion criteria. Coughlan Cronin and Ryan (2013) further stated that the formulations of the inclusion and the exclusion criteria help the researcher of a systematic qualitative research to successfully filter out the literary articles which falls beyond the scope of the study from the ocean wide pool of research. In the domain of the selection of the inclusion and exclusion criteria, Polit and Beck (2014) came up with the opinion that the inclusion and the exclusion criteria of the research must be selected strategically in order to selectively mark the boundaries of the research. Proper selection of the inclusion and exclusion criteria helps the research to obtain relevant hits from the electronic databases. This not only help to fetch relevant hits, but also helps to avoid unwanted wastage of time in screening a gamut articles Parahoo (2014) stated that the selection of the inclusion and the inclusion criteria must be justified. For example, the selection of the exclusion criteria that is too specific leads to an unwanted omission of numerous relevant research articles which other-wise might be helpful for the research. On the other hand, the selection of the inclusion criteria must not be too broad so that it might lead to unwanted scanning of articles which fall beyond the scope of the study leading to loss of valuable time of the researcher.

Inclusion and Exclusion Criteria of the Research
Inclusion Criteria	Exclusion Criteria
Primary and secondary research	Case studies and case reports
Language: English	Other than English
Country: United Kingdom	Countries other than United Kingdom
Year of publication: 2008 to 2018	Published before 2008
Peer reviewed journal article
Research methods: Qualitative and Quantitative

Both primary as well as secondary research along with qualitative and quantitative research will be used for the conducted of the systematic review because, it will help the researcher to increase the number of hits of research articles which are based on the UK perspective. Te time filter selected for the research will be last 10 years; this will again help to increase the research hits of studies based on the UK perspective. Moreover, there are no significant research conducted over the UK perspective over smoking and diabetes development during the last 10 year. Only peer reviewed journals will be used for the conduction of the systematic review in order to increase the overall strength of the study (Parahoo 2014).

The table below highlights the keywords that will be used for the conduction of the search of the literary articles online

Keyword 1	Type 2 Diabetes Mellitus	OR	Type 2 Diabetes
	AND
Keyword 2	Smoking	OR	Tobacco Smoking
	AND
Keyword 3	United Kingdom	OR	UK
	AND
Keyword 4	Young Adults	OR	College students

Table: The list of keywords that will be used for the search of literary articles

Source: Created by author

According to Betanny-Saltikiv (2012), the use of the keywords helps in the refinement of the literature search through the electronic databases. Moreover, the use of limiters as highlighted by the inclusion and exclusion criteria of research helps make the search results specific. Here AND and OR are used as Boolean operators, which is again regarded as the limiters for the database search. Robband Shellenbarger (2014) stated that the use of the Boolean operators is an important part of the search of literary articles with the help of keywords. The use of the Boolean search operators, AND/OR will help the research to obtain different permutation and combination of keywords. Moreover, the use of the Boolean operator will help the researcher to save a huge amount of time by reducing the number of insignificant hits.

Quality Assessment will be done in an ordered and in a sequential manner, The quality assessment of the article will be initiated by removing the duplicate from the result obtained after search. After the removal of the duplicates, the selected articles will be reviewed based on their title. According to Parahoo (2014), the title of the article must be judged in an ordered manner before the final selection for the systematic review. The title of the article must clearly describe the aim of the study, research approach and selected population. After the title scrutiny and exclusion of the article based on the title scrutiny, the articles will be screened based on the abstract. The articles which will be selected after the abstract analysis will be reviewed for the full-text analysis before the final selection of the articles for the systematic review. In the full-text scrutiny of the articles, the main points that will be taken under detailed consideration includes: sample size of the article, selection bias, confounding bias, allocation bias and reporting bias. Of this, confounding bias will be given prime importance. According to Parahoo (2014), confounding bias generates when the nature of the participants included under the text group and the placebo ground are not be similar characteristic or not given equal treatment. In order critically analyse the articles based on the all the level of bias sample size, the author will make use of a critical analysis tool from the Joanna Briggs Institute (JBI). JBI tool will be used for critical analysis because it has different framework for the reviewing of different types of research articles like Experimental designs, quasi-experimental study (systematic review of the randomised control trials, randomised control trials and other quantitative study designs), observational-analytical study (cohort studies, case control studies), observational-descriptive study (Cross-sectional studies), and bench research (systematic review for the expert opinion).

Secondary analysis of the data mainly refers to the use of the existing data in order to find the answer to the research questions that was different from the original word. Secondary data in this research might deal with a large scale of survey or data which are collected as the part of personal research. Thus the main ethical consideration under the secondary research revolves around potential harm to the individual subjects and the issues in regards to the return for the consent (Tripathy 2013). Tripathy (2013) is of the opinion that in qualitative secondary research, the culture of the data archiving is absent and there also exists a concern that archiving of data might expose the personal views of that particular person. Thus in case of highlighting any personal data from case control studies, the research will mainly follow the anonymisation. The researcher will also cite the source of the data in order to follow the guidelines of the copy-right and the data-protection act. 

Main activities/ stages	Week 1	Week 2	Week 3	Week 4	Week 5	Week 6	Week 7
Data collection from primary and secondary sources based on the selected inclusion and exclusion criteria and search filters	·	·
Critical analysis of the selected papers through JBI tool		·
Selection of the final research articles for the systematic review		·	·	·
Thematic analysis of the data from the final selected papers			·	·
Analysis & Interpretation of Data Collection					·	·
Conclusion						·
Submission of the Final Work						·	·

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